E. Wesley Ely, MD, MPHProfessor of Medicine

Vanderbilt University, Nashville, TNVA TN Valley Health Care System GRECC

CUSP4MVP-VAPSATs and SBTs: of Guidelines & Implementation

Disclosures: ICU Physician Vanderbilt - Abbott, Hospira, Orion- NIH and VA U.S. Federal Funding- Author of PAD Guidelines of SCCM 2013- Chair of SCCM Delirium section for PAD - Co-Chair of SCCM ICU Liberation project to aid world-wide implementation

Barr J, et al. Crit Care Med. 2013;41:263-306.

AgitationPai

n

Delirium

Barr J et al, CCM 2013;41:263-306

Clinical Practice Guidelines for the sustained use of sedatives and analgesics in the critically ill adult

Jacobi, CCM 2002

Clinical Practice Guidelines for the management of Pain, Agitation, and Delirium in adult patients in the Intensive Care Unit

Barr, CCM 2013

New guidelines emphasize individual symptom management

OLD(2002)

New(2013)

Take Home Message

Delirium = Dangerous

Andros Island by N Rakov, NEJM 2011;365:457

Patient = Vulnerable

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50-70%Cognitively Impaired

Wolters Intensive Care Med 2013; 39: 376Jackson AJRCCM 2010; 182: 183

Girard Crit Care Med 2010; 38: 1513

Latronico Lancet Neurol 2011; 10: 931

60-80%Functionally

Impaired

Mar

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ICU Survivorship

Family

Hobbies

WorkIwashyna Annals of Int Med 2010; 153:204-5

...like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something…

-SB

“©

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Mild Cognitive Impairment

Moderate/Severe Cog Impairment

20

15

10

5

0

% survivors cognitively impaired

-3 years -1 year +1 year + 3 years

25

p<0.001After SepsisBefore Sepsis

Iwashyna T, JAMA 2010;304:1787-1794

Cognitive Impairment: Sepsis

Ely EW, JAMA 2004;291:1753-62

Shehabi Y, et al. CCM 2010; 38:2311–2318

Delirium Duration & MortalityRe

lativ

e H

azar

d of

D

eath

0 1 2 3 4 5 60

1

2

3

4

p<.001

Days of Delirium

0 vs 1 HR 1.7 1.27-2.29 <0.001

0 vs 2 HR 2.69 1.58-4.57 <0.001

0 vs 3 HR 3.73 1.92-7.23 <0.001

NEJM 2013;369:1306-16Editorial by M. Herridge

Gunther M et al. CCM 2012;40:2022-32

(A) 46 year old, no delirium (B) 42 year old, 12 days of delirium

Delirium and Brain Atrophy

The Picture of Dementia Following ICU Care

Global Cognitive Scores by Age

Global Cognitive Scores by Age and Comorbidity

Primum non Nocere - Hippocratic Oath- First do no harm

“Nothing to Fear but Fear Itself” - FDR inauguration, 1933- Overcome Fear of ICU Culture Change

So let’s focus on potentially modifiable aspects of care such as potent medications, delirium, and

improving care and clinical outcomes…

EDCBA

ABCDEs:Building blocks of managing

Pain, Agitation & Delirium

Awake and Breathing Coordination

Choose light sedation & avoid benzos

Delirium monitoring & management

Early Mobility & Environment

Duration of mechanical ventilation Duration of coma Mortality

Duration of mechanical ventilation Mortality Delirium

Duration of delirium Disability ICU Length of Stay Rehospitalization/Mortality

Morandi et al Curr Opin Crit Care 2011;17:43-9Vasilevskis et al Crit Care Med 2010;38:S683-91Vasilevskis et al Chest 2010;138:1224-1233Zaal et al, ICM 2013;39:481-88Colombo et al, Minerva Anest 1012;78:1026-33

Delirium detection

Pain, Agitation, and Delirium Are Interrelated

Barr J, et al. Crit Care Med. 2013;41:263-306.

AgitationPai

n

Delirium

“Pain should be routinely monitored in all adult ICU patients”

Grade 1B Recommendation

2013 PAD Guidelines:

Crit Care Med. 2013;41:263-308

Pain, Agitation, and Delirium Are Interrelated

Barr J, et al. Crit Care Med. 2013;41:263-306.

AgitationPai

n

Delirium

Targeted Level of Consciousness

Choose Target RASS

Assess Actual RASS

Modify treatment so Actual = Target

“We recommend either daily sedation interruption or a light level of target

sedation be routinely used…”Grade 1B Recommendation

2013 PAD Guidelines:

Crit Care Med. 2013;41:263-308

“We recommend that sedative medications be titrated to maintain a light* rather than

deep level of sedation”

Grade 1B Recommendation

2013 PAD Guidelines:

Crit Care Med. 2013;41:263-308

*Light sedation = RASS 0 to -2

Awake and Breathing Coordination

Choose light sedation & avoid benzos

Delirium monitoring & management

Early Mobility & Environment

Duration of mechanical ventilation Duration of coma Mortality

Duration of mechanical ventilation Mortality Delirium

Duration of delirium Disability ICU Length of Stay Rehospitalization/Mortality

Morandi et al Curr Opin Crit Care 2011;17:43-9Vasilevskis et al Crit Care Med 2010;38:S683-91Vasilevskis et al Chest 2010;138:1224-1233Zaal et al, ICM 2013;39:481-88Colombo et al, Minerva Anest 1012;78:1026-33

Delirium detection

Ely EW, et al. N Engl J Med 1996;335:1864-9

0

20

40

60

80

100

Pat

ient

s on

Ven

tilat

or (

%)

0 302010 155 25

Control (n =151)

Protocol (n =149)

p<.001

Time (Days)

Liberating from VentilatorSBT reduced weaning time by =

2 days

0

20

40

60

80

100

Pat

ient

s on

Ven

tilat

or (

%)

0 302010 155 25

Control (n=60)

Protocol (n=68)

Adjusted p<.001

Time (Days)

Liberating from Sedation

Kress JP, et al. N Engl J Med 2000;342:1471-7

SAT reduced ventilator time by =

2 days

SAT + SBT = 4 day shorter ICU/hosp LOS

Patie

nts

Aliv

e (%

)

00

20

40

60

80

100

60 120 180 240 300 360

Days

Control (n=168)

ABC approach (n=167)

ABC Trial: One-Year Survival

p=.01

NNT=7

Girard TD, et al. Lancet 2008;371:126-34

Mehta S, JAMA 2012;308:1985-92

Sedation Interruption in SLEAP

Benzodiazepine Use in Trials *

Study Control TreatmentKress NEJM 2000 90 mg/day 53 mg/day

Girard ABC Lancet 2007 84 mg/day 54 mg/day

Mehta SLEAP JAMA 2012 82 mg/day 102 mg/day

OSCILLATE NEJM 2013 141 mg/day 199 mg/day

* All values converted and expressed as mean midazolam dose per patient, median for ABC study were 8 mg and 5 mg, respectively

SPICE Study – first 48 hoursmean 50 mg/d benzos

Shehabi AJRCCM 2012;186:724-31

Awake and Breathing Coordination

Choose light sedation & avoid benzos

Delirium monitoring & management

Early Mobility & Environment

Duration of mechanical ventilation Duration of coma Mortality

Duration of mechanical ventilation Mortality Delirium

Duration of delirium Disability ICU Length of Stay Rehospitalization/Mortality

Morandi et al Curr Opin Crit Care 2011;17:43-9Vasilevskis et al Crit Care Med 2010;38:S683-91Vasilevskis et al Chest 2010;138:1224-1233Zaal et al, ICM 2013;39:481-88Colombo et al, Minerva Anest 1012;78:1026-33

Delirium detection

No Sedation: ICU Length of Stay

0

Days7

0

20

40

60

80

100Pa

tient

s Re

mai

ning

in IC

U (%

)

14 21 28

Intervention (n=55)

Control (n=58)

Strom T, et al. Lancet 2010;375:475-80

ICU stay reduced by 9.7 days

“We suggest that sedation strategies using non-benzodiazepines (propofol or

dexmedetomidine) may be preferred over sedation with benzodiazepines (midazolam

or lorazepam)”

Grade 2B Recommendation

2013 PAD Guidelines:

Crit Care Med. 2013;41:263-308

Pain, Agitation, and Delirium Are Interrelated

Barr J, et al. Crit Care Med. 2013;41:263-306.

AgitationPai

n

Delirium

Awake and Breathing Coordination

Choose light sedation & avoid benzos

Delirium monitoring & management

Early Mobility & Environment

Duration of mechanical ventilation Duration of coma Mortality

Duration of mechanical ventilation Mortality Delirium

Duration of delirium Disability ICU Length of Stay Rehospitalization/Mortality

Morandi et al Curr Opin Crit Care 2011;17:43-9Vasilevskis et al Crit Care Med 2010;38:S683-91Vasilevskis et al Chest 2010;138:1224-1233Zaal et al, ICM 2013;39:481-88Colombo et al, Minerva Anest 1012;78:1026-33

Delirium detection

Cardinal Symptoms of Delirium and Coma

Morandi A, et al. Intensive Care Med. 2008;34:1907-1915.

“We recommend routine monitoring for delirium in adult ICU patients”

Grade 1B Recommendation

2013 PAD Guidelines:

Crit Care Med. 2013;41:263-308

Delirium and Executive Function

If delirium is not screened for using a validated delirium screening tool it is missed ~75% of time.

Inouye SK Arch Intern Med. 2001;161:2467-2473.Devlin JW Crit Care Med. 2007;35:2721-2724.Spronk PE Intensive Care Med. 2009;35:1276-1280.van Eijk MM Crit Care Med. 2009;37:1881-1885.

Ely EW, JAMA 2001;286:2703-10

Ely EW, JAMA 2003;289:2983-91

Medical Intensive Care Unit

Don’t forget about Dr. DRE

Diseases Sepsis, COPD, CHF

Drug Removal SATs and stopping benzodiazepines/ narcotics

Environment Immobilization, sleep and day/night, hearing aids, glasses, noise

Brain Road Map(A framework for bedside rounds)

3. How did they get there?Drugs

1. Where is the patient going?Target RASS

2. Where is the patient now?Current RASS

Current CAM-ICU© B

rian Slo

an via F

lickr

ExcellenceAristotle: “We are what we repeatedly do.

Excellence is not an act, but a habit”

Jiro Dreams of Sushi - Tokyo

EDCBA

ABCDEs:Building blocks of managing

Pain, Agitation & Delirium

“ I survived and that is the main thing. And I am so grateful to God that I survived and am now off all oxygen and consider myself all well except that I can’t remember to take my medications...

-SB

“©

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The ICU Delirium and Cognitive Impairment Study Group at the Loveless Café, Nashville TN

ICU Delirium and Cognitive Impairment Study Group: selected local members

Pratik PandharipandeJim JacksonJin HanEd VasilevskisChris HughesAlessandro MorandiPaula WatsonLorraine WareGordon BernardBob DittusTed SperoffWes Ely

Leanne BoehmJoyce OkahashiCayce StrengthBrenda PunLauren HardyAmy LipseyRyan BlackJessica McCurleyMichael SantoroCarrie JonesMorgan CrawfordMayur Patel

Tim GirardJohn GoreBaxter RogersStephan HeckersCathy FuchsHeidi SmithTy BeruttiBrad StrohlerElizabeth CardJennifer ThompsonAyumi ShintaniStephanie Hamilton

Key Epidemiological Points:1) Patients suffer from long-lasting and disabling aspects of critical

illness that demand our attention as a medical community2) Acquired or accelerated cognitive impairment is a major public

health problem following ICU care for both the old and young3) This cognitive impairment appears most pronounced in domains

of executive dysfunction and memory4) Frontal lobe and hippocampal atrophy are being consistently

found in recent studies5) This injury is likely distinct from or complementary to

Alzheimer’s pathology, though we are in our infancy in learning about this entity (e.g., large pathology study under review)

6) Delirium and drug exposure appear to be the most modifiable aspects of care, with need for more trials to delineate next steps

Key Management Points:1) Establish an overarching protocolized approach to daily ICU

patient management using 2013 PAD Guidelines2) Assess & treat pain first (may be sufficient)3) If patient remains agitated after adequately treating pain, use

prn/bolus sedation initially, if frequent boluses (>3/hr) use continuous sedation

4) Avoid benzodiazepines in most patients5) Turn off sedation daily and restart only if needed at lowest dose

to maintain chosen target level of consciousness6) Deep sedation (RASS -4/-5) appears harmful; target awake/alert7) Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek

reversible causes and attempt non-pharmacologic management8) Use the ABCDEs to improve outcomes for your patients

CUSP4MVP-VAP project measures

• As part of this project, teams will collect and receive reports for metrics to support your improvement efforts.

• We held calls with your data facilitator. The data collection tool, including instructions are available at:

https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/datatools.aspx

Medical Intensive Care Unit

CUSP4MVP Data CollectionSedation and Delirium

1) Percentage of RASS/SAS actual being {-1, 0, 1} or {4, 5}

2) Percentage of achieving RASS/SAS target3) Distribution of RASS/SAS actual scores4) Delirium assessment compliance rate5) Percentage of incorrectly reporting CAM-ICU/

ASE UTA (higher is worse)6) Percentage of CAM-ICU negative or ASE <=2

(no delirium)Medical Intensive Care Unit

CUSP4MVP Data CollectionSAT/SBT (next call on March 18)

(1) SAT compliance rate(2) SBT compliance rate(3) SAT contraindication rate(4) SBT contraindication rate

(5) Percentage of ventilated patient days without sedation(6) SBT with Seds off compliance rate

(7) SAT contraindication distribution plot and table (counts and percentages)

(8) SBT contraindication distribution plot and table (counts and percentages)

Medical Intensive Care Unit

Your Next Steps:

• Share your protocols regarding sedation and delirium management; will share with other participating teams• Email to CUSP4MVP@jhmi.edu

• Review data collection requirements and develop plan to collect and submit data.

Medical Intensive Care Unit

Reminder:

By Content Call, Module 5 (April 1, 2014):1. Watch the Science of Safety (SOS) Video

– http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04a_scisafety/index.html

2. Develop a method to deliver the SOS Video to your entire unit’s staff

3. Administer the SSA and submit aggregated results to CE

4. Facilitate at least one team meeting

Next Call

March 18, 2014

SAT / SBTDr Mike Klompas